Every finding on record at Avalon Place

Based on record review and interview the facility failed to provide nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 (#55 & #77) sampled residents. The facility failed to ensure: 1) Nursing staff had a documented assessment or rationale for Resident #55 having an x-ray of her foot in the medical record prior to the x-ray being completed 2) Nursing staff completed and recorded an assessment for Resident #77 on 06/17/2025 when she complained of abdominal pain before being transferred to a local hospital on [DATE] for treatment of the abdominal pain.Findings:Resident #55 Review of the record for Resident #55 revealed diagnoses in part of unspecified sequelae of cerebral infarction, biliary cirrhosis, heart failure, diabetes, and gout. Review of Resident #55's, most recent, MDS dated [DATE] revealed the resident's BIMS score was 15 which indicated no cognitive impairment. Review of Resident #55's record revealed an x-ray report dated 08/15/2025 including two views of the left foot to rule out fracture with no additional documentation of the rationale for the x-ray. During an interview on 12/02/2025 at 4:39 p.m., S2DON confirmed the facility had no evidence to show nursing staff completed an assessment of Resident #55 for an X-ray to be completed on 08/15/2025 and there should have been documentation of the rationale for the X-ray. During an interview on 12/02/2025 at 4:44 p.m., S1Administrator confirmed the facility had no evidence to show nursing staff completed an assessment for Resident #55 to explain the reason the resident had an X-ray on 08/15/2025. Resident #77 Review of the record for Resident #77 revealed an admission date of 10/17/2024 with diagnoses that included Parkinson's Disease, chronic obstructive pulmonary disease, hypertension, gastroesophageal reflux disease, pain, and edema. Resident #77 was a full code. Additionally, the record revealed Resident #77 was admitted to the hospital on [DATE]. Review of the Significant Change MDS assessment dated [DATE] revealed Resident #77's BIMS score as unable to be assessed. Additionally, the MDS assessment revealed that Resident #77 did not have an ostomy and was dependent with toileting hygiene. Review of Resident #77's Comprehensive Plan of Care revealed an update on 06/28/2025 with a focus of alteration in bowel elimination related to colostomy. In an interview on 12/02/2025 at 4:15 p.m., S7LPN reported hospice staff were notified on 06/17/2025 that Resident #77's responsible party voiced concerns related to Resident # 77's status which included shortness of breath, pain, and decreased intake. S7LPN reported that the responsible party suggested that Resident #77 be transferred to the Emergency Department. S7LPN reported not recalling being aware of Resident #77's code status, and it was S7LPN's understanding that the decision to transfer the resident to the Emergency Department was the hospice provider's decision. In an interview on 12/02/2025 at 2:40 p.m., S8LPN reported Resident #77 was transferred to the Emergency Department due to a significant change in status. Review of hospital records, with admission date 06/18/2025, revealed that Resident #77 was diagnosed with perforation of the sigmoid colon due to diverticulitis which required surgery that resulted in colostomy placement. On 12/03/2025 at 3:00 p.m., S2DON confirmed that there was no documentation to support that Resident #77 was competently assessed by S7LPN.

Based on record reviews and interviews, the facility failed to ensure accuracy of the MDS assessment for 2 (#76 and #77) of 3 sampled residents reviewed.Findings:Resident #76 Review of Resident #76's record revealed an admission date of 11/10/2025 with diagnoses including atherosclerotic heart disease of native coronary without angina pectoris, polyneuropathy, chronic systolic (congestive) heart failure, unspecified dementia unspecified severity with other behavioral disturbance, hypertension, and chronic obstructive pulmonary disease. Review of Resident #76's MDS assessments revealed an admission/Medicare 5 day MDS assessment with an ARD of 11/17/2025. Further review of the MDS revealed a BIMS score of 11 indicating moderate cognitive impairment and the resident's current tobacco use was marked as no. Review of Resident #76's smoking assessment dated [DATE] revealed the resident was a safe smoker and her cigarettes and lighter are kept at the nurse's station. Review of Resident #76's current care plan revealed a care plan for potential for injury related to smoking. Interventions included to monitor resident during smoking every shift, do not permit book matches to be used, and cigarettes and lighter kept at the nurse's station. An interview on 12/02/2025 at 2:30 p.m. with S1Administrator confirmed Resident #76 was a smoker. An interview on 12/03/2025 at 10:10 a.m. with S4ADON confirmed Resident #76 was identified as a smoker upon admission. S4ADON confirmed she failed to identify Resident #76 as a smoker on the Admission/5 day Medicare MDS assessment dated [DATE]. An interview on 12/03/2025 at 4:25 p.m. with S5ADON confirmed the facility failed to identify Resident #76 was a smoker on the Admission/5 day Medicare MDS assessment dated [DATE]. Review of the record for Resident #77 revealed an admission date of 10/17/2024 with diagnoses that included Parkinson's Disease, chronic obstructive pulmonary disease, hypertension, gastroesophageal reflux disease, pain, and edema. Review of the Significant Change MDS assessment dated [DATE] revealed Resident #77's BIMS score as unable to be assessed. Additionally, the MDS assessment revealed that Resident #77 did not have an ostomy and was dependent with toileting hygiene. Review of Resident #77's Comprehensive Plan of Care revealed an update on 06/28/2025 with a focus of alteration in bowel elimination related to colostomy with interventions that included colostomy care as ordered and monitor for signs and symptoms of skin breakdown daily during daily care. On 12/03/2025 at 2:15 p.m., S2DON confirmed that the MDS was inaccurate as it documented Resident #77 as having no colostomy.

Based on observation, interview and record review, the facility failed to ensure residents received reasonable accommodation of needs in accordance with preferences for 1(#28) of 1 sampled residents reviewed for accommodation of needs by failing to provide a manual wheelchair for Resident #28 for mobility when the resident's electric scooter was not functioning. Findings: Record review revealed Resident #28 was admitted to the facility on [DATE]. Resident #28 had diagnoses that included diabetes, peripheral vascular disease, and acquired absence of left leg above the knee. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 15 which indicated no cognitive impairment. Review of an annual MDS dated [DATE] revealed Resident #28 used an electric scooter or manual wheelchair for mobility.On 12/01/2025 at 3:16 p.m., an observation and interview were conducted in Resident #28`s room. An electric scooter was observed in the room. Resident #28 reported the electric scooter did not have a working battery and the facility did not provide replacement batteries. Resident #28 reported he wanted a manual wheelchair in his room so he could get out of bed and move around. On 12/02/2025 at 4:41 p.m., an observation of Resident #28`s room revealed there was not a manual wheelchair available in the room. On 12/02/2025 at 4:49 p.m., an interview with S2DON confirmed Resident #28 did not have a manual wheelchair or a working motorized wheelchair in his room. S2 DON confirmed Resident #28 needed a wheelchair for mobility.

Based on record review and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive plan of care for 1 (#77) of 2 (#20, #77) reviewed for colostomy care. Findings:Review of the facility's Colostomy/Ileostomy Care Policy dated 01/15/2025 revealed, in part:PurposeThe purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matterDocumentationThe following information should be recorded in the resident's medical record1. The date and time the colostomy/ileostomy care was provided2. The name and title of the individual(s) who provided the colostomy/ileostomy care3. Any breaks in resident's skin, signs of infection (purulent discharge, pain, redness, swelling, temperature), or excoriation of the skin4. How the resident tolerated the procedure5. If the resident refused the procedure, the reason(s) why and the intervention taken6. The signature and title of the person recording the dataReporting1. Notify the supervisor if the resident refuses the colostomy/ileostomy care2. Notify the supervisor of any abnormal findings (i.e. breaks in skin, excoriation, signs of infection, etc).3. Report other information in accordance with facility policy and professional standards of practice. Review of the record for Resident #77 revealed an admission date of 10/17/2024 with diagnoses that included Parkinson's Disease, chronic obstructive pulmonary disease, hypertension, gastroesophageal reflux disease, pain, and edema.Review of the Significant Change Minimum Data Set assessment dated [DATE] revealed Resident #77's BIMS score as unable to be assessed. Additionally, the MDS assessment revealed that Resident #77 did not have an ostomy and was dependent with toileting hygiene. Review of Resident #77's Comprehensive Plan of Care revealed an update on 06/28/2025 with a focus of alteration in bowel elimination related to colostomy with interventions that included colostomy care as ordered and monitor for signs and symptoms of skin breakdown daily during daily care. Review of the Physician's Orders revealed an order dated 06/28/2025 as follows: Check stoma site every shift for swelling and redness. Change colostomy bag as needed every shift. Review of the June and July 2025 MAR revealed no documentation to support that the order was completed from 06/28/2025-07/07/2025.Review of the nursing notes revealed that Resident #77 was transferred to the Emergency Department for evaluation on 07/07/2025 and returned to the facility on [DATE]. Review of the hospital's discharge summary note with admission date of 07/07/2025 revealed on 07/08/2025 bowel noted to be abnormal in color at ostomy site and questionable gangrene. Consulted surgery. On 07/09/2025, viable tissue underneath the superficial sloughing. Additionally, the discharge summary note revealed that colostomy complication was noted and resolved during the admission. On 12/03/2025 at 3:04 p.m., S2DON confirmed that there was no documentation to support that colostomy care was performed from 06/28/2025-07/07/2025.

Based on record review and interview the facility failed to ensure a comprehensive plan of care was developed for 1 (#20) of 1 resident that developed COVID-19. Findings:Review of the record for Resident 20 revealed admitting diagnoses in part of Polyosteoarthritis, Seborrheic Dermatitis, Major Depressive Disorder, Hypertension, History of colon cancer with colostomy placement and Atrial Fibrillation.Review of the Physician orders revealed an order for COVID test as needed and orders dated 11/07/2025 for COVID and FLU swab. Review of the laboratory results for the Respiratory Life Panel with COVID 19 and Influenza A and B testing with results dated 11/10/2025 revealed Resident 20 tested positive for COVID 19. Further review of the Physician orders dated 11/11/2025 revealed orders for Complete Blood Count (CBC), Complete Metabolic Panel (CMP), D-dimer 2 times per week for 3 weeks, Chest Xray 2 times per week for 3 weeks, Vitamin C 1000 milligrams by mouth twice a day for 2 weeks, Zinc Sulfate 220 milligrams by mouth every day for 2 weeks, Augmentin 875/125 milligrams by mouth twice a day for 10 days, and Azithromycin 500 milligrams by mouth give 1 today and then 250 milligrams by mouth every day for 4 days. Further review of the record revealed Resident 20 was placed on COVID isolation. Review of the plan of care for Resident 20 revealed no focus area, goals, or interventions were developed in the plan of care when Resident 20 was diagnosed with COVID on 11/10/2025. On 12/03/2025 at 1:56 p.m., an interview with S2DON confirmed there was no plan of care developed when Resident 20 tested positive for COVID on 11/10/2025.

Based on record reviews and interviews, the provider failed to ensure the MDS assessments were transmitted to the state in a timely manner for 1 (#2) of 3 sampled residents reviewed.Findings:Review of Resident #2's record revealed an admission date of 05/06/2025.Review of Resident #2's MDS assessments revealed a significant change MDS assessment dated [DATE]. Further review of the MDS history revealed this MDS was not transmitted to the state until 12/03/2025 (during the survey).An interview on 12/03/2025 at 10:00 a.m. with S5ADON revealed the significant change MDS assessment dated [DATE] for Resident #2 was not transmitted to the state until 12/03/2025. S5ADON reported she was not responsible for transmission of the MDS assessments. An interview on 12/03/2025 at 10:10 a.m. with S4ADON confirmed she was responsible for transmitting all of the MDS assessments for the facility into the state system. S4ADON confirmed she failed to transmit Resident #2's significant change MDS assessment dated [DATE] in a timely manner to the state.

Based on record reviews and interviews, the facility failed to inform the resident's physician and /or the resident's representative when a significant change in the resident's physical, mental, or psychosocial status or a decision to transfer or discharge a resident from the facility. The facility failed to:1.) notify the resident's physician and the resident's representative of a change in condition on 09/26/2025 when Resident #72 was transferred to the emergency room, and2.) notify the resident's physician of a change in condition for Resident #77. Findings: Resident #72 Review of Resident #72's record revealed and admission date of 09/02/2025 with diagnoses including type 2 diabetes mellitus with diabetic chronic kidney disease, chronic atrial fibrillation, idiopathic gout right knee, and hypertension. Review of Resident #72's MDS assessment dated [DATE] revealed a discharge return anticipated MDS was completed. Review of the record revealed Resident #72 was transferred and admitted to the hospital on [DATE]. Further review of the record revealed no documented evidence that the facility notified the resident's physician or the resident's representative of Resident #72's transfer to the local emergency room on [DATE]. An interview on 12/03/2025 at 1:45 p.m. with S5ADON confirmed Resident #72 was transferred to the hospital on [DATE]. S5ADON further confirmed the facility failed to have documented evidence that Resident #72's physician or representative were notified that the resident was transferred to the hospital on [DATE]. Resident #77 Review of the record for Resident #77 revealed an admission date of 10/17/2024 with diagnoses that included Parkinson's Disease, chronic obstructive pulmonary disease, hypertension, gastroesophageal reflux disease, pain, and edema. Resident #77 was a full code. Additionally, the record documented Resident #77 was transferred to the hospital on [DATE]. Review of Resident #77's Comprehensive Plan of Care revealed an update on 06/28/2025 with a focus of alteration in bowel elimination related to colostomy. Review of hospital records, with admission date 06/18/2025, revealed that Resident #77 was diagnosed with perforation of the sigmoid colon due to diverticulitis which required surgery that resulted in colostomy placement. In an interview on 12/02/2025 at 4:15 p.m., S7LPN reported hospice staff were notified on 06/17/2025 that Resident #77's responsible party voiced concerns related to Resident # 77's status which included shortness of breath, pain, and decreased intake. S7LPN reported that the responsible party suggested that Resident #77 be transferred to the Emergency Department. S7LPN reported not recalling being aware of Resident #77's code status, and it was S7LPN's understanding that the decision to transfer the resident to the Emergency Department was the hospice provider's decision. On 12/03/2025 at 3:00 p.m., S2DON confirmed that there was no documentation to support that the physician was notified of Resident #77's status change on 06/17/2025.

Based on record reviews, and interviews, the facility failed to ensure notifications of changes in resident conditions were made, as evidenced by the facility failing to ensure the resident's physician was notified of an incident for 1 (#1) of 3 (#1, #2, and #4) residents reviewed for notification of change. Findings: Review of the facility's Change in a Resident's Condition or Status Policy undated revealed: Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc). Review of the medical record for resident #1 revealed an admitted [DATE] with diagnoses including unspecified dementia with other behavioral disturbance, depression, and hypothyroidism. Review of the resident #1's medical record revealed no documentation of an Admit Minimum Data Set Assessment (MDS) due to the resident was transferred to the emergency roiagnom on [DATE]. Resident #1 was discharged from the facility on 10/26/2024 before the Admit MDS assessment could be completed. Review of resident #1's Baseline Care Plan revealed she was confused, nonverbal, and required 1 person assistance with all activities of daily living. Review of the Incident/Accident (IA) Reporting Form dated 10/26/2024 at 10:15 a.m., revealed S4Licensed Practical Nurse (LPN) was summoned to the locked unit by S3Certified Nursing Assistant (CNA). S3CNA reported that resident #1 sat on the floor and when she got up she hit the left side of her head on a chair. S4LPN found the resident sitting on buttocks with legs extended out in front of her. Resident #1 was assessed for injuries and she had a knot on the side of her head (left side per diagram). There was no bleeding or any other visible injuries. Resident #1 was moving her extremities continuously. Further review of the IA report revealed the resident's physician was notified on 10/26/2024 at 10:20 a.m. However, there was no time documented for time the physician responded. An interview with S3CNA on 12/04/2024 at 12:15 p.m., revealed she witnessed the above incident. She reported the object that resident #1 bumped her head on was the table in the day room in the locked unit. S4LPN documented in the above IA Report that the object was a chair, which was incorrect. A phone interview with S4LPN was conducted on 12/03/2024 at 9:35 a.m. S4LPN revealed she tried to contact the resident's physician regarding the above incident on 10/26/2024 at 10:20 a.m but the physician's phone number in the computer was not up to date. She called the phone number but it had been disconnected. S4LPN revealed she tried to look up the physician's new number on her phone but couldn't find it. S4LPN confirmed she failed to find out the physician's new number at that time and resident #1's physician was not notified of the incident on 10/26/2024 at 10:20 a.m. An interview with S2Interim Director of Nursing on 12/04/2024 at 10:00 a.m. confirmed S4LPN should have notified resident #1's physician regarding the above incident that occurred on 10/26/2024 at 10:15 a.m.

Based on interview and record review, the facility failed to ensure that a resident who required dialysis received services consistent with professional standards of practice by failing to ensure fluid restrictions were followed and implemented as ordered for 1 (#3) of 1 sampled residents who were reviewed for dialysis. Findings: Review of the medical record revealed resident #3 was admitted on [DATE]. Her diagnoses included end stage renal disease, hypertensive heart disease and unspecified psychosis. Review of the October 2024 physician orders revealed the resident received dialysis on Monday, Wednesday and Friday and had a 1000 cc fluid restriction. There was no documentation in the medical record that resident #3's fluid intake was being monitored. On 10/15/2024 at 1:55 p.m., interview with S5Certified Nurse Aid (CNA) revealed she worked in the memory care unit where resident #3 resided. S5CNA reported they did not keep a fluid intake log for resident #3. On 10/25/2024 at 2:15 p.m., interview with S2Assistant Director or Nursing (ADON) confirmed the staff were not documenting resident #3's fluid intake to ensure it stayed within the fluid restriction.

Based on observations, record reviews and interviews, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 (#25 and #70) of 9 (#5, #12, #17, #25, #38, #52, #69, #70 and #175) residents reviewed for accident hazards. The facility failed to 1) complete an Incident/Accident report after residents #25 and #70 had an incident, and 2) assess resident #70 to determine if the lap tray was appropriate after he slid under the lap tray. Findings: Resident #70 Review of the medical record for resident #70 revealed an admitted [DATE] with diagnoses of edema, depression, muscle weakness, seizures, hypertension and lack of coordination. Review of the physician's orders dated 10/05/2024 for resident #70 revealed an order to use a geri chair when the resident was out of the bed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #70 had a Brief Interview for Mental Status (BIMS) score of 2 which indicated severe cognitive impairment for daily decision making and he required assistance with activities of daily living (ADLs). Review of the current careplan revealed resident #70 was at high risk for injury due to the resident uses a geri chair with a lap tray. On 10/14/2024 at 10:00 a.m. and 2:10 p.m., observations of resident #70 revealed he was sitting in a geri chair with a lap tray. On 10/15/2024 at 9:18 a.m., and on 10/16/2024 at 9:00 a.m., observations of resident #70 revealed he was sitting in a geri chair with a lap tray. Review of the nurses' notes dated 10/06/2024 at 10:04 p.m. revealed resident #70 had behaviors throughout the entire weekend. Resident #70 was yelling, screaming, cursing at staff, and undressing in the day room and in his room. The resident slides down in the geri chair under the lap tray and gets on the floor, banging on the lap tray with his fist, and bumping his knee on the tray attempting to remove the tray. Review of the record revealed no documented evidence that an Incident/Accident Reporting form was completed on 10/06/2024 when the resident was noted sliding down in the geri chair under the lap tray and getting on the floor. Further review of the record revealed no documented evidence that resident #70 was assessed for the use of a lap tray to ensure the assistive device was appropriate after the incident on 10/06/2024 when he slid under the lap tray. On 10/16/2024 at 11:50 a.m., an interview with S2Assistant Director of Nursing (ADON) revealed she was unaware that resident #70 slid under the lap tray on 10/06/2024 as stated in the nurses' notes. . On 10/16/2024 at 1:55 p.m. interview with S2ADON confirmed an Incident/Accident Report Form should have been completed for resident #70 for the incident noted in the nurses' notes dated 10/06/2024 when he slid under the lap tray. S2ADON further confirmed the resident should have been assessed for the need of the lap tray to determine if the lap tray was an appropriate assistive device. 43405 Resident #25 Review of the medical record for resident #25 revealed an admitted [DATE] with diagnoses including vascular dementia unspecified severity with other behavioral disturbance, cerebrovascular disease, Alzheimer's disease early onset, pseudobulbar affect, anxiety disorder, type 2 diabetes mellitus, hypotension, and major depressive disorder. Review of the Quarterly MDS assessment dated [DATE] revealed resident #25 had a BIMS score of 2 indicating severe cognitive impairment. Further review of the MDS revealed he was dependent on staff for all activities of daily living. Observations on 10/14/2024 at 9:25 a.m. and 10/15/2024 at 12:42 p.m. revealed resident #25 was in a geri chair with lap tray, in his room. Observation of resident #25 on 10/16/2024 at 11:10 a.m. revealed resident was up in his geri chair with a lap tray in the dayroom. Review of resident #25's nurses' notes dated 08/11/2024 at 11:28 a.m. revealed nurse was summoned to resident's room per certified nursing aide (CNA) that stated resident broke his lap tray and slid on the floor. Resident was found sitting on buttocks in front of his geri chair with legs drawn toward his chest and resident was unable to say what happened. Treatment to skin tear to left elbow and assisted back to bed. Review of the medical record revealed no incident/accident report was done for this incident on 08/11/2024. Review of resident #25's careplan dated 02/07/2022 revealed resident at risk for fall. Further review revealed the careplan was not updated with a fall on 08/11/2024. An interview on 10/16/2024 at 2:50 p.m. with S2ADON confirmed that an incident/accident report was not completed on 08/11/2024 on resident #25, and should have been completed on 08/11/2024 when resident #25 broke his lap tray and slid onto the floor.

Based on record reviews, observations, and interviews, the facility failed to implement policies and procedures for enhanced barrier precautions (EBP) for 3 (#18, #28, and #35) of 3 (#18, #28, and #35) residents reviewed for enhanced barrier precautions. Findings: Review of the Enhanced Barrier Precautions (EBP) policy and procedure dated 04/01/2024 revealed the following in part: Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are indicated for residents with any of the following: -colonization with a Center for Disease Control and Prevention (CDC)- targeted Multidrug-resistant organism (MDRO) when Contact Precautions do not otherwise apply; or -wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with MDRO. Indwelling medical devices examples include central lines, urinary catheters, feeding tubes, and tracheostomies. Communication to Staff The facility will utilize postings outside the room and Point Click Care to communicate to staff if a resident requires EBP. Resident #18 Review of resident #18's record revealed an admitted [DATE] with diagnoses including urinary retention, fibromyalgia, hypertension, paroxysmal atrial fibrillation, hypothyroidism, and urinary tract infection. Review of resident #18's October 2024 Physician's Orders revealed the following orders: 09/04/2024- Foley catheter care every shift, clean with soap and water every shift 3 times per day and 18 French Foley catheter, change every month on the 4th of the month and as needed for dislodgement, diagnoses urinary retention; and 09/21/2024- enhanced barrier precautions during high contact-resident care activities every shift 2 times per day. Review of resident #18's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitively intact. Further review of the MDS revealed the resident required substantial/maximal assistance with activities of daily living and has an indwelling urinary catheter. Observations on 10/14/2024 at 10:30 a.m. and 10/15/2024 at 12:45 p.m. revealed resident #18 had an indwelling urinary catheter and did not have an EBP sign posted on her door. An interview on 10/15/2024 at 12:58 p.m. with S2Assistant Director of Nursing (ADON) confirmed that the facility failed to post the EBP sign on resident #18's door and should have EBP due to resident #18 having a urinary catheter. Resident #28 Review of resident #28's record revealed an admitted [DATE] with diagnoses including unqualified visual loss both eyes, benign prostate hypertrophy, glaucoma, chronic kidney failure, hypertension, unspecified dementia, and alcohol abuse. Review of the Quarterly MDS assessment dated [DATE] revealed BIMS score of 14 indicating cognitively intact. Further review of the MDS revealed the resident required substantial/maximal assistance with activities of daily living and has dialysis. Review of resident #28's October 2024 Physician's Orders revealed an order dated 08/02/2024 for dialysis every Tuesday, Thursday, and Saturday. Observation on 10/14/2024 at 9:35 a.m. and 10/15/2024 at 12:58 a.m. revealed resident #28's door did not have an EBP sign posted. Interview on 10/15/2024 at 12:58 p.m. with S2ADON confirmed resident #28's door did not have an EBP sign posted and confirmed resident #28 had a dialysis access to right chest wall and required EBP while he has an indwelling medical device. 18118 Resident #35 Review of the medical record for resident #35 revealed an admitted [DATE] with diagnoses of insomnia, anxiety, dementia, enlarged prostate, hyperlipidemia, and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] revealed resident #35's BIMS score was 14 which indicated intact cognition for daily decision making. Resident #35 required assistance with activities of daily living. Review of the current care plan revealed resident #35 had an indwelling catheter and to use EBP as ordered. Review of the physician's orders dated 10/03/2024 revealed EBP during high contact resident care activities every shift. On 10/15/2024 at 8:35 a.m., 10:15 a.m., and 11:00 a.m., observations of resident #35 revealed he had an indwelling catheter and observation of the resident's door revealed the door did not have signage indicating that the resident required EBP. On 10/15/2024 at 1:10 p.m., observation of #35's door with S2ADON revealed the resident had an indwelling catheter. S2ADON confirmed the door should have signage that indicated EBP should be taken when providing high contact care to the resident.

Based on observations of medication administration, record review, and interview, the facility failed to ensure that it was free from a medication error rate of 5% or greater. The facility had a 10.71% medication error rate with 3 medication errors out of 28 opportunities. Findings: Resident #43 An observation of the medication administration for resident #43 on 10/15/2024 at 8:33 a.m. with S4Licensed Practical Nurse (LPN) revealed S4LPN administered Furosemide 20 milligrams (mg) 1 tablet by mouth and administered Gabapentin 100 mg 1 capsule by mouth. Review of the October 2024 Physician's orders for resident #43 revealed the following orders: 02/13/2024 Gabapentin 300 mg capsule by mouth 2 times per day (BID) at 9:00 a.m. and 5:00 p.m; and 09/23/2024 Furosemide 40 mg tablet: take 1 tablet by mouth (40 milligrams total dose) at 8:00 a.m. every Tuesday, Thursday, Saturday, and Sunday. An interview on 10/15/2024 at 1:30 p.m. with S2Assistant Director of Nursing (ADON) confirmed that S4LPN should have administered Furosemide 40 mg by mouth and Gabapentin 300 mg by mouth to resident #43 during the morning medication pass on 10/15/2024. Resident #44 An observation of the medication administration for resident #44 on 10/15/2024 at 8:15 a.m. with S4LPN revealed S4LPN administered Fludrocortisone 0.1 mg 1 tablet by mouth. Review of the October 2024 Physician's Orders for resident #44 revealed an order dated 09/10/2024 for Fludrocortisone 0.1 mg tablet: take 2 tablets by mouth (0.2 mg total dose) at 8:00 a.m. every day. An interview on 10/15/2024 at 1:30 p.m. with S2ADON confirmed that S4LPN should have administered Fludrocortisone 0.1mg, 2 tablets by mouth to resident #44 during the morning medication pass on 10/15/2024. S2ADON further confirmed that 3 medication errors occurred on the morning medication pass and the medication error rate was greater than 5%.

Based on observations, record reviews and interviews, the facility failed to ensure residents were assessed for the risk of entrapment from bed rails prior to the installation of bed rails for 4 (#5, #12, #17, and #38) of 5 (#5, #12, #17, #38 and #52) residents reviewed for bed rails. Findings: Review of the facility's undated Physical Restraints, Side Rails policy revealed: Purpose The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines 3. As assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails, when used for mobility or transfer, an assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails; and d. That the bed's dimensions are appropriate for the resident's size and weight. 4. The use of side rails as an assistive device will be addressed in the resident care plan. Resident #17 Review of the medical record for resident #17 revealed an admitted [DATE] with diagnoses including depression, hypotension, edema, hypokalemia, muscle weakness and anemia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #17's Brief Interview for Mental Status (BIMS) score was 15 which indicated intact cognition for daily decision making. Resident #17 required assistance with activities of daily living. Observations on 10/14/2024 at 11:05 a.m. and 10/15/2024 at 11:00 a.m. of resident #17's room revealed the bed rails were raised on both sides of the bed. On 10/16/2024 at 8:10 a.m., an observation of the resident revealed she was in the bed with bed rails raised on both sides of the bed. Review of the record revealed no documented evidence of an assessment for the risk of entrapment for the bed rails. On 10/16/2024 at 11:45 a.m., an interview with S2Assistant Director of Nursing (ADON) revealed the facility did not assess for the risk of entrapment for the use of bed rails for resident #17. Resident #38 Review of the medical record for resident #38 revealed an admitted [DATE] with diagnoses including diabetes mellitus, depression, history of falling, vascular dementia, pseudobulbar affect, hemiplegia following cerebral infarction, and osteoarthritis. Review of the quarterly MDS assessment dated [DATE] revealed resident #38 had a BIMS score of 12 which indicated the resident had moderate cognitive impairment for daily decision making. Resident #38 required assistance with activities of daily living. On 10/14/2024 at 2:47 p.m., 10/15/2024 at 1:35 p.m. and 10/16/2024 at 7:30 a.m., observations of resident #38's room revealed bed rails were in the raised position on both sides of the bed. Review of the care plan dated 10/28/2022 revealed resident #38 had impaired mobility related to hemiplegia. Further review of the care plan revealed the interventions were to provide assistive devices as needed for transfers/mobility and to have turning bars to assist with bed mobility. Review of the record revealed no documented evidence of an assessment for the risk of entrapment for the bed rails. On 10/16/2024 at 11:45 a.m., an interview with S2ADON revealed the facility did not assess for the risk of entrapment for the use of bed rails for resident #38. 32231 Resident #12 Review of the medical record revealed resident #12 was readmitted to the facility on [DATE] with diagnoses including in part, generalized muscle weakness, heart failure, intervertebral disc, dementia with behavioral disturbance, and repeated falls. Review of the medical record revealed a pre-restraining evaluation dated 09/01/2024. Review of the evaluation revealed the interdisciplinary team's recommendations was for resident #12 to have a turning bar to assist with turning and repositioning. Further review revealed resident #12 had a documented BIMS score of 09. A score of 08-12 revealed the resident had moderate cognitive impairment with daily decision making skills. Review of the annual MDS assessment dated [DATE] revealed resident #12 required partial to moderate assistance with rolling from left to right, sitting to lying, lying to sitting, sitting to standing, and from a chair to the bed. On 10/14/2024 at 11:22 a.m., an observation revealed resident #12 in her room and lying in bed. Further observation revealed there were two bed rails intact, one to each side of the resident's bed. The bed rails were up and in a locked position. On 10/15/2024 at 8:52 a.m., resident #12 was observed in her room and was resting in bed. Further observation revealed the bed rails remained up and in a locked position. Review of the medical record revealed there was no documented evidence of resident #12 being assessed for entrapment regarding the use of the bed rails. On 10/16/2024 at 5:00 p.m., an interview with S2ADON confirmed there was no documented evidence of resident #12 being assessed for the risk of entrapment regarding the use of the bed rails. On 10/16/2024 at approximately 5:45 p.m., S7Corporate Administrator and S1Administrator notified of the above findings. 43405 Resident #5 Review of the medical record for resident #5 revealed an admitted [DATE] with diagnoses of mononeuropathy, hypertension, type 2 diabetes mellitus without complications, pressure ulcer, and hyperlipidemia. Review of resident #5's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Further review of the MDS revealed resident required substantial/maximal assistance with activities of daily living. Observations of resident #5 on 10/14/2024 at 11:45 a.m. and 10/16/2024 at 8:22 a.m. revealed resident #5 was lying in bed with bilateral bed rails in the up position. Review of resident #5's October 2024 Physician's Orders revealed an order dated 04/12/2023 for siderails (bed rails) up while in bed to assist with bed mobility. Review of the medical record revealed no documented bed rail assessment for the risk of entrapment for resident #5. An interview on 10/16/2024 at 11:50 a.m. with S2ADON confirmed there was no documented assessment for the risk of entrapment with bed rail use for resident #5.

Based on observations, record reviews, and interviews, the facility failed to ensure a resident with pressure ulcers recieved the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 (#6 and #52) of 5 (#5, #6, #18, #52, and #125) residents investigated for pressure ulcers. The facility failed to ensure that a pressure relieving device was implemented for resident #52, who currently had a new, unidentified pressure to her left heel. Findings: Resident #6 Review of the medical record revealed resident #6 was admitted to the facility on [DATE]. Further review revealed her diagnoses included in part, dementia without behavioral disturbance and a history of pressure ulcers. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed resident #6 had a brief interview for mental status (BIMS) score of 09. A score of 08-12 indicated resident #6 had moderate cognitive impaired with daily decision making skills. On 10/14/2024 at 2:35 p.m., an observation revealed resident #6 lying in bed in her room. Further observation revealed the resident's feet were both pressed against the footboard of the bed. Resident #6 reported that her feet were hurting and that she had requested a pillow to go underneath her ankles and legs to keep her feet from touching the mattress. S12Certified Nursing Assistant (CNA) was notified of the residents' request for a pillow. While S12CNA was positioning the resident's lower extremities, an observation revealed some brownish-yellow colored areas of drainage on the bedsheet located underneath the left heel. A visual skin inspection of the left heel with S12CNA revealed an open area to the ball of resident #6's left heel. Further observation revealed the skin had separated from the heel. S12CNA left the resident's room to notify the nurse of the findings. On 10/14/2024 at approximately 2:40 p.m., S9Licensed Practical Nurse (LPN) arrived to the room. She was notified of the findings regarding the drainage and open area to resident #6's left heel. S9LPN observed the heel and revealed that resident #6 had previously had skin breakdown to her heels approximately one to two months ago, but they had since heeled. S9LPN was further notified of the residents' request for a pillow to be positioned underneath her lower extremities due to her complaints of pain. S9LPN revealed that resident #6 had previously complained of pain in her feet, but she (S9LPN) had not assessed the resident's feet at that time as the resident was already taking medication for pain. S9LPN confirmed there was no type of pressure relieving device underneath resident #6's lower extremities to help keep the resident's feet off of the bed mattress and to aide in the prevention of further skin breakdown. On 10/16/2024 at approximately 5:45 p.m., S7Corporate Administrator and S1Administrator were notified of the above findings. Resident #52 Review of the medical record revealed resident #52 was admitted to the facility on [DATE] with diagnoses including in part, dementia without behavioral disturbance and a history of pressure ulcers. Review of the MDS assessment dated [DATE] revealed resident #52 had a documented BIMS score of 99 which indicated that she had severe cognitive impairment with daily decision making skills. Further review revealed resident #52 was dependent upon staff for all activities of daily living. On 10/14/2024 at 10:22 a.m., an observation revealed resident #52 sitting up in a geri chair, in the dayroom. Further observation revealed there was no type of pressure relieving device in the seat of the geri chair. On 10/16/2024 at approximately 5:30 p.m., resident #52 was observed sitting in her geri chair, in the main dining room. Observation revealed there was not any type of pressure relieving device in the seat of the geri chair. S2Assistant Director of Nursing (ADON) was present during the observation. S2ADON revealed that resident #52 currently had a Stage II facility acquired pressure ulcer to the right hip. S2ADON confirmed there was no type of pressure relieving device in the seat of the geri chair to help prevent further skin breakdown. On 10/16/2024 at approximately 5:45 p.m., S7Corporate Administrator and S1Administrator were notified of the above findings.

Based on observations, record reviews, and interviews, the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet the resident's needs by not having documentation of the character of urine every shift for 1 (#18) of 1 residents reviewed for urinary catheters. Findings: Review of the Catheter Care Urinary Policy and Procedure updated 01/12/2024 revealed the following in part: Documentation The following information should be recorded in the resident's medical record: 1. Date and time catheter care was given. 2. The name and title of the individual giving the catheter care. 3. All assessment data obtained when giving catheter care. 4. Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor. Review of resident #18's medical record revealed an admitted [DATE] with diagnoses including urinary retention, fibromyalgia, hypertension, paroxysmal atrial fibrillation, hypothyroidism, and urinary tract infection. Review of resident #18's October 2024 Physician's Orders revealed the following orders: 09/04/2024- Foley catheter care every shift, clean with soap and water every shift 3 times per day and 18 French Foley catheter, change every month on the 4th of the month and as needed for dislodgement, diagnoses urinary retention; and 09/21/2024- enhanced barrier precautions during high contact; resident care activities every shift 2 times per day. Review of resident #18's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 14 indicating cognitively intact. Further review of the MDS revealed resident #18 required substantial/maximal assistance with activities of daily living and had an indwelling urinary catheter. Observations on 10/14/2024 at 10:30 a.m. and 10/15/2024 at 12:45 p.m. revealed resident #18 had an indwelling urinary catheter. Review of resident #18's careplan dated 09/05/2024 revealed urinary catheter: indwelling urine retention chronic urinary tract infection with an intervention to assess color, clarity, and character of the urine and catheter care every shift. Review of resident #18's September and October 2024 Medication Administration Record (MAR) revealed no documented evidence of staff assessing the color, clarity, and character of resident's urine. An interview on 10/15/2024 at 12:58 p.m. with S2Assistant Director of Nursing confirmed the facility failed to implement the careplan for resident #18, by failing to document the color, clarity, and character of the resident's urine every shift.

Based on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the resident's status for 1 (#72) of 3 (#72, 73, 74) residents selected for closed record reviews. Findings: Review of the discharge Minimum Data Set (MDS) assessment for resident #72 revealed the resident was discharged to the hospital on 09/30/2024. Review of the nurse's notes revealed resident #72 was discharged to home. On 10/16/2024 at 4:05 p.m., an interview with S2Assistant Director or Nursing confirmed the resident was discharged home. On 10/16/24 at 4:15 p.m., an interview with S6Licensed Practical Nurse confirmed the MDS incorrectly indicated resident #72 was discharged to the hospital rather than to home.

Based on record reviews and interview, the facility failed to assess residents using the quarterly review instrument specified by the State and approved by Centers for Medicare and Medicaid Services (CMS) not less frequently than once every 3 months for 2 (#25 and #27) of 2 residents sampled for Minimum Data Set (MDS) Assessments. Findings: Resident #25 Review of resident #25's record revealed an admitted [DATE]. Further review of the record revealed the resident's last Quarterly MDS Assessment with an Assessment Reference Date (ARD) of 06/25/2024 and no documented Quarterly MDS for resident #25. Resident #27 Review of resident #27's record revealed an admitted [DATE]. Further review of the record revealed the resident's last Quarterly MDS Assessment with ARD of 06/04/2024 and no documented Quarterly MDS for resident #27. An interview on 10/16/2024 at 7:45 a.m. with S2Assistant Director of Nursing (ADON) confirmed that the Quarterly MDS Assessments for resident #25 and resident #27 were not completed within 3 months of the previous Quarterly MDS Assessments.

Based on record review and interviews, the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and send a copy of the notice to a representative at the Office of the State Long-Term Care Ombudsman for 1 (#12) of 1 (#12) reviewed for hospitalization s. Findings: Review of the Emergency Transfer Logs for June 2024 and July 2024 revealed resident #12 was discharged to the hospital on the dates of 06/23/2024 and 07/17/2024. Further review revealed there was no documented evidence of the Ombudsman being notified of resident #12 being transferred to the hospital on 06/23/2024 and 07/17/2024. On 10/16/2024 at 5:12 p.m., during a telephone interview with the local Ombudsman assigned to the nursing facility, she confirmed that she had not been notified of resident #12's transfers to the hospital on the dates of 06/23/2024 and 07/17/2024. On 10/16/2024 at approximately 5:45 p.m., S7Corporate Administrator and S1Administrator were notified of the above findings.

Based on observations, record reviews, and interviews, the facility failed to ensure residents were free from physical restraints imposed for the purpose of discipline or convenience for 3 (#25, #52 and #70) of 3 residents reviewed for restraints. The facility failed to have documented evidence of monitoring the release of the lap trays for residents #25, #52 and #70 and failed to have physician orders for the lap trays for residents #25 and #70. Findings: Review of the facility's Use of Restraints policy and procedure, revised December 2007, revealed the following, in part: Policy Interpretation and Implementation 2. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which staff applied it given that resident's physical condition (i.e., side rails put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. 3. Examples of devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove. 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. the specific reason for the restraint (as it relates to the resident's medical condition) b. how the restraint will be used to benefit the resident's medical condition; and c. the type of restraint, and period of time for the use of the restraint. 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom, but the underlying problems that may be causing the symptom. 18. Care plans shall also include the measures taken to systemically reduce or eliminate the need for restraint use. Review of the facility's undated Informed Consent for Use of Physical Restraint revealed the following, in part: a staff member shall assess restrained residents every 30 minutes, for physical needs and comfort, and release the restraint for 10 minutes at least every 2 hours, changing position, toileting, and performing range of motion exercises to all extremities, as part of the resident's plan of care. Resident #70 Review of the medical record for resident #70 revealed an admitted [DATE] with diagnoses of edema, depression, muscle weakness, seizures, hypertension and lack of coordination. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #70 had a Brief Interview for Mental Status (BIMS) score of 2 which indicated severe cognitive impairment for daily decision making and the resident required assistance with activities of daily living (ADLs). Review of resident #70's October 2024 physician's orders revealed a physician's order dated 10/05/2024 to use a geri chair when the resident was out of the bed. Further review of the physician's orders revealed no order for the use of a lap tray. Review of the current careplan revealed resident #70 was at high risk for injury due to the resident used a geri chair with a lap tray. On 10/14/2024 at 10:00 a.m. and 2:10 p.m., observations of resident #70 revealed he was sitting in a geri chair with a lap tray. On 10/15/2024 at 9:18 a.m. and 10/16/2024 at 9:00 a.m., observations of resident #70 revealed he was sitting in a geri chair with a lap tray. Review of resident #70's Pre-Restraining assessment dated [DATE] revealed the resident had a geri chair with a lap tray to assist with trunk control. Review of the Informed Consent for Use of Physical Restraint dated 09/01/2024 for resident #70 revealed use of a geri chair with lap tray, physical restraint for trunk control. Review of the record revealed no documentation of monitoring the release of the lap tray at least every 2 hours for resident #70. On 10/16/2024 at 1:55 p.m., an interview with S2Assistant Director of Nursing (ADON) confirmed resident #70 did not have a physician's order for use of a lap tray. S2ADON confirmed resident #70 did not have any documentation of monitoring the release of the lap tray for resident #70. 32231 Resident #52 Review of the medical record revealed resident #52 was admitted to the facility on [DATE] with diagnoses including in part, dementia without behavioral disturbance and a history of falls. Review of the Significant Change in Status MDS assessment dated [DATE] revealed resident #52 had a BIMS score of 99 which indicated the resident had severe cognitive impairment with daily decision making skills. Further review revealed resident #52 was dependent upon staff for all activities of daily living. Review of resident #52's Pre-Restraining Evaluation form dated 09/18/2024 revealed an interdisciplinary team evaluation revealed a recommendation for resident #52 to have a geri chair with a lap tray to assist with poor trunk control and forward leaning. Review of the Informed Consent for Use of Physical Restraint dated 09/01/2024 for resident #52 revealed use of a geri chair with lap tray for trunk control. Review of the medical record revealed there was no documented evidence of monitoring for the release of the lap tray at least every two hours for resident #52. On 10/14/2024 at 10:22 a.m., an observation in the dayroom revealed resident #52 sitting up in a geri chair. Further observation revealed a lap tray was intact to the geri chair. Further observation revealed the resident's hand were closed and contracted. On 10/16/2024 at 11:45 a.m., an interview with S2ADON confirmed there was no documented evidence in the medical record to address monitoring for the release of resident #52's lap tray. She further confirmed resident #52 had contractures to both hands and could not remove the lap tray. On 10/16/2024 at approximately 5:45 p.m., S7Corporate Administrator and S1Administrator were notified of the above findings. 43405 Resident #25 Review of the medical record for resident #25 revealed an admitted [DATE] with diagnoses including vascular dementia unspecified severity with other behavioral disturbance, cerebrovascular disease, Alzheimer's disease early onset, pseudobulbar affect, anxiety disorder, type 2 diabetes mellitus, hypotension, and major depressive disorder. Review of resident #25's October 2024 Physician's Orders revealed there was no order for the use of a geri chair or a lap tray. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS score of 2 indicating severe cognitive impairment. Further review of the MDS revealed dependence on staff for all activities of daily living and no physical restraint was marked on the MDS. Observations on 10/14/2024 at 9:25 a.m. and 10/15/2024 at 12:42 p.m. revealed resident #25 was in a geri chair with lap tray in his room. Observation of resident #25 on 10/16/2024 at 11:10 a.m. revealed resident was up in a geri chair with a lap tray in the dayroom. An interview on 10/16/2024 at 8:15 a.m. with S3Certified Nursing Aid (CNA) revealed resident #25 was not able to release the lap tray on his geri chair. Review of resident #25's Pre-Restraining assessment dated [DATE] revealed resident had a geri chair for poor trunk control, but did not identify the use of a lap tray while in the geri chair. Review of the Informed Consent for Use of Physical Restraint dated 09/01/2024 for resident #25 revealed use of a geri chair with lap tray, physical restraint, purpose- poor trunk control, to be applied when out of bed. Review of the record revealed no documentation of monitoring the release of the lap tray at least every 2 hours for resident #25. An interview on 10/16/2024 at 1:55 p.m. with S2ADON confirmed resident #25 was not able to release the lap tray on his geri chair. S2ADON confirmed resident #25 did not have a physician's order for the use of a geri chair or a lap tray. S2ADON further confirmed resident #25 did not have any documentation of monitoring the release of the lap tray for resident #25.

Based on record reviews, and interviews, the facility failed to ensure notifications of changes in resident conditions were made, as evidenced by the facility failing to ensure 1) the resident's representative was notified after resident #69 had a fall, and 2) staff notified the nurse when resident #6 was found to have bruises for 2 (#6 and #69) of 2 residents reviewed for notification of change. Findings: Review of the facility's Change in a Resident's Condition or Status Policy undated revealed: Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc). Resident #69 Review of the medical record for resident #69 revealed an admitted [DATE] with diagnoses including pulmonary edema, hypertension, dementia, muscle weakness, and cerebral infarction. Review of the current Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment for daily decision making. Further review of the MDS revealed resident #69 required assistance with activities of daily living. Review of the Incident/Accident Reporting Form dated 10/14/2024 revealed resident #69 was found lying in the supine position on the floor mat. Further review of the report revealed there was no documented evidence that S4Licensed Practical Nurse (LPN) notified the family of the fall. On 10/15/2024 at 1:50 p.m., an interview with S4LPN confirmed she did not inform the family that the resident had a fall on 10/14/2024. On 10/16/2024 at 2:45 p.m., an interview with S2Assistant Director of Nursing (ADON) confirmed S4LPN should have notified the responsible party on 10/14/2024 that #69 had a fall. 32231 Resident #6 Review of the medical record revealed resident #6 was admitted to the facility on [DATE]. Further review revealed her diagnoses included in part, dementia without behavioral disturbance and a history of pressure ulcers. Review of the annual MDS assessment dated [DATE] revealed resident #6 had a BIMS score of 09. A score of 08-12 indicated resident #6 had moderately impaired cognitive skills for daily decision making. On 10/14/2024 at 2:30 p.m., an observation revealed resident #6 in her room and resting in bed. Further observation revealed the resident's feet were both pressed against the footboard of the bed. Further observation revealed resident #6 had purple colored bruising to the top of her left foot between the resident's great toe and the distal interphalangeal joints. There was further bruising observed to the outer, lateral part of the left foot. S9LPN was notified of the bruising. On 10/16/2024 at 12:00 p.m., S2ADON and S8ADON were notified of resident #6 having bruising observed to the top of her left foot. S2ADON and S8ADON performed an inspection of resident #6's skin. Observation revealed two dime sized areas of greenish-yellow bruising to the resident's outer biceps of her right arm. Further observation revealed one small area of bruising to the back of the resident's inner, lateral part of the right knee and a second area that was approximately dime sized to the back of her left leg, below the bend of the knee. During an interview with resident #6, resident #6 revealed she could not recall exactly how the bruising had occurred. Both S2ADON and S8ADON confirmed they were not aware of resident #6's bruises. They further confirmed that staff were to notify them upon discovery of any injury of unknown origin. On 10/16/2024 at approximately 5:45 p.m., S7Corporate Administrator and S1Administrator were notified of the above findings.

Based on observation, record review and interview the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents by: 1) failing to thoroughly investigate falls, 2) failing to implement the care plan for falls, 3) failing to implement new approaches after a fall and 4) failing to provide increased supervision for 1 (#2) of 5 (#1, #2, #3, #4 and #5) sampled residents with multiple falls. This failure placed resident #2 in an Immediate Jeopardy situation which began on 11/07/14 at 5:36PM after the resident returned back to the facility from the hospital with a [DIAGNOSES REDACTED]. The facility failed to initiate any new or different approaches to address resident #2's needs to prevent falls. S1 Administrator, S2 Corporate Administrator were notified of the Immediate Jeopardy on 12/11/14 at 3:11PM. The facility submitted a plan of removal which included: 1) Resident #2 will be provided one on one supervision until transferred to a safer environment. Will work with MD and family to arrange safe location. 2) All residents have the potential to be affected by the deficient practice. 3) Will in-service staff on fall prevention, fall investigation, filling out I&A properly to assess if current interventions were in place and that a new appropriate intervention was put in place. DON and ADON will track and trend all I&A ' s and change fall prevention needs as needed. DON/ADON/Administrator/Designee will physically monitor staff supervision on night shift 3 times per week for 4 weeks including weekends, then randomly thereafter to ensure safety is maintained. 4) If any problems are found they will be addressed at that time. The Immediate Jeopardy situation was removed on 12/12/14 at 9:47AM when the above plan of removal was accepted. The deficient practice remains at level of actual harm. Findings: Review of the medical record revealed resident #2 was a [AGE] year old female that was admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Review of the Wandering/Elopement Risk Assessment updated 08/05/14 revealed resident was at risk for elopement/wandering. Interventions included safety alarm devices, staff aware of resident wander risk, wander guard in place and need for constant redirection. (Wandering/Elopement Risk Assessment was 82 days past due). Review of the Fall Risk Assessment updated 08/05/14 revealed a score of 13 which indicated resident #2 was a high risk for falls. (Fall Risk Assessment was 82 days past due). Review of the 09/22/14 quarterly MDS, documented a reentry date of 08/05/14 from psychiatric hospital. Review of the MDS revealed resident was severely cognitively impaired, required supervision/set up help with bed mobility, transfer, walk in room/ corridor, and locomotion on and off unit. Further review revealed resident #2's balance was not steady with walking, was occasionally incontinent of bladder and always continent of bowel. Review of the December 2014 physician orders [REDACTED]. shift, Wander guard at all times and monitor placement and function every shift, self -releasing seatbelt with alarm to wheelchair as safety precaution dated 09/04/14. Care Plan Review: Review of the care plan dated 06/30/14 revealed resident #2 was identified to be at risk for impaired mobility related to confusion, delirium with a goal that resident would be free from falls daily with the following approaches: provide assistance with ambulation as needed, encourage resident to participate in transfers, provide assistive device as needed for transfers/mobility, provide assistance with transfers, observe for excessive fatigue and/or falling, self-releasing seat belt to wheelchair as safety precaution with alarm. Further review of the record revealed a care plan was developed 06/30/14 that identified resident #2 was at risk for falls related to Alzheimer's, behavior with problems, confusion and delirium with a goal that resident #2 would have safe falls without injury this quarter with the following interventions: keep adjustable bed in low position for safe transfers, keep call light within reach at all times, monitor every 2 hours, ensure that resident wears properly fitting non-skid shoes for ambulation, encourage resident to request assistance with transfers, lock bed and w/c for safe transfers, self -releasing seat belt with alarm and wander guard at all times. It was noted that bed alarm as ordered by the MD was scratched through and not listed as an intervention to prevent falls. Further review revealed an original care plan dated 09/10/13 that was developed for falls for resident #2. This original care plan included some of the same approaches that were listed on the 06/30/14 care plans that were noted above but also included the following approaches: place on fall prevention program, place visual cue beside resident ' s name on door to alert staff that resident was high risk for falls, wheelchair alarm, low bed with mat in place (not dated). Further review revealed the care plan was updated as follows: 11/02/14 - resident admitted to hospital with [DIAGNOSES REDACTED]. Further review of the care plan revealed resident #2 constantly transfers self and was non-compliant with safety devices. There was no check noted beside bed alarm as an intervention. On 12/10/14 at 1:00PM interview with S3DON reported the approach implemented on 11/22/14 to toilet every 2 hours even at night was intended to tire her out so that she would sleep for longer intervals at night. Review of the aide care plan provided to the surveyor on 12/11/14 revealed bed pad alarm was checked and auto nurse alarm was written out beside it and a check was noted for floor mat and was dated 11/02/14. (The bed pad alarm was not noted on resident #2's care plan in the medical record and the floor mat was not dated as to when it was initiated on the care plan. On 12/9/14 at 10:30AM observation revealed resident #2 was self propelling herself in a w/c down the hall. Resident able to voice her name to surveyor but was confused. A bruise was noted to the right side of her face in the cheek area and a large knot noted at right temporal area. The surveyor questioned resident #2 about what happened and she stated she didn't know. On 12/11/14 at 11:10AM observation revealed resident #2 wandering around the facility in her wheelchair. Resident was observed to go up to med cart and start taking med cups off of the cart. Observations on 12/09/14 -12/11/14 during the survey revealed there was no pommel cushion noted to the resident's recliner. On 12/11/14 at 3:00PM interview with S3DON reported one of the CNA's had put the pommel cushion in resident #2's w/c and it should only be placed in her recliner. Review of the Facility's Nurse Notes: Review of the nurse notes dated 11/03/14 at 10:20PM revealed resident #2 complained of upper leg pain upon movement. No redness or swelling noted and there was adequate range of motion. MD notified by fax. There was no documentation an assessment was made of resident #2's pain during the night shift. Review of nurse notes dated 11/04/14 at 10:57AM revealed the nurse went down to room to assist CNA with dressing resident #2. When trying to get her pants up, resident yelled out in pain when her leg was picked up. Resident sent to hospital for evaluation. At 2:15PM the facility was advised resident #2's hip was broken. At 2:59PM, nurse spoke with hospital and was informed resident went straight from the emergency room to surgery. Review of the nurse notes dated 11/16/14 at around 12:30AM revealed CNA reported resident #2 got out of bed and urinated on floor. CNA assisted resident to wheelchair and resident self propelled herself to the nurse station. On 11/16/14 at 10:21PM documentation revealed resident #2 continuing to get up with no assistance. Review of the nurse notes dated 11/19/14 at 1:49AM revealed resident awake, moving about facility via wheelchair. Resident confused and asks repetitive questions about where her room was. Review of the nurse notes dated 11/20/14 at 12:39AM revealed resident #2 wakes during the night and sits up on side of bed and attempts to get out of bed. Resident is also able to unlock seatbelt when up in wheelchair. CNA instructed to remain at door of resident in between rounds due to high risk for falls. Review of the nurse notes dated 11/22/14 at 10:56AM revealed resident #2 asks to urinate every 30 minutes to an hour; she will void about 15 mls when she does. Review of the nurse notes dated 11/24/14 at 12:50AM revealed resident #2 was up in wheelchair rolling around facility with wheelchair seatbelt intact. Resident stated she was not tired at this time. At 2:15AM, resident remains up in wheelchair in hallway, refuses to go to bed, stated she wasn't tired. Resident was able to propel self around the facility and self releasing seat belt intact. Review of the nurse note dated 11/24/14 at 11:29AM revealed resident #2 back from emergency room with a large bruise and swelling to right side of head. Resident also complained of pain to right shoulder - both CT scans and x-rays came back negative for fractures. Review of the nurse notes from November -December nurse notes revealed no daily documentation of a bed pad alarm, auto nurse alarm, floor mat or dual wander guards. The following days revealed documentation of fall interventions in place: On 11/25/14 night shift documented sensor alarm to bed; 11/27/14 night shift - clip alarm to chair, sensor alarm to bed; 11/29/14 night shift - clip alarm to bed; 12/01/14 evening shift - bedside mat, clip alarm to chair, sensor alarm to bed; 12/06/14 night shift- sensor alarm to bed; 12/07/14 evening shift- landing mat and bed alarm in place and functioning properly. Review of the November and December 2014 Medication Administration Record revealed no documentation that resident #2 had a floor mat or a bed pad alarm in place. Further review revealed there was no documentation the auto nurse alarm or dual wander guards were in place for resident #2 after they were implemented after falls. Review of the Incident and Accident Log for resident #2 from October - December 2014 revealed the following falls: 10/17/14 at 2:21AM - resident found sitting on buttock in front of her wheelchair in the hallway. Resident reported she was trying to sit down in her wheelchair and fell on to the floor. Wheelchair wheels were not locked. Husband and physician were notified. Review of the investigation report revealed resident was attempting to sit down in her wheelchair and fell . Immediate intervention to the fall was resident kept up in wheelchair with staff at nurse station until she became sleepy. The approach added by the fall committee/DON was to provide assistance for all transfers. (This approach was already in place according to the care plan). There was no documentation that the self-releasing seat belt alarm sounded for the resident at the time of the fall. 10/27/14 at 10:40PM - resident's room. Nurse called to resident #2's room by the CNA. Resident noted on floor beside bed in seated position. No apparent injuries and no complaints of pain. Resident stated she did not remember why she got out of bed. Husband and MD notified. Review of the fall investigation report revealed the immediate intervention after the fall was resident #2 was sent back to bed and the CNA sat outside the resident's room to monitor closely. The approach added by the fall committee/DON was monitor resident every 2 hours. (This approach was already in place according to the plan of care). There was no documentation that a bed alarm sounded for the resident at the time of the fall and the I&A report did not indicate if the bed was in the low position. There was no further documentation indicating the CNA sat outside the resident's room the remainder of the shift. 11/01/14 at 6:18AM - resident ' s room. Resident found on floor on side of bed sitting on buttocks. Resident had bowel movement on her body. Resident reported that she "fell going to the bathroom" , able to stand and lift legs, complained of no new pain, just stated "only my back hurts, my back always hurts." Review of the fall investigation revealed resident was going from bed to the bathroom with complaints of diarrhea. Immediate intervention to the fall was the CNA dressed and provided pericare and resident was assisted up to wheelchair at the nurse station. The approach added by the fall committee/DON was encouraged to request for assistance for all transfers. (This approach was already in place according to the care plan and the resident's cognition was severely impaired). There was no documentation that the bed was in the low position or that the bed alarm sounded for the resident at the time of the fall. 11/02/14 at 1:30AM - nurse was summoned to resident's room by the CNA. When she arrived, the resident was lying on the floor beside her bed. Resident stated, "I fell out of the bed." No injuries noted. Resident able to stand with assistance. Able to move upper and lower extremities, assisted back to bed with bed in low position and call light in reach. Husband notified at end of shift and MD was notified via fax. Review of the fall investigation revealed the immediate response to the fall was instructed CNA to check on resident as often as possible and the nurse made sure the bed was in the low position and placed call light within easy reach. The approach added by the fall committee/DON was keep bed in low position. (This approach was already in place according to the care plan). There was no documentation that the bed alarm sounded for the resident at the time of the fall and there was no documentation that CNA checked on resident #2 more frequently. 11/14/14 at 1:15AM in resident's room. This nurse was summoned to resident #2' s room by the CNA, resident was found lying on floor on her back. She had removed her brief and verbalized that she had tried to go to bathroom and I think I hit my head. Resident able to move upper/lower extremities. Further review revealed it was noted that the resident's left hip was red and painful to touch. The nurse assisted aide with reapplying brief and placed pillow under head for comfort. CNA remained with aide and the nurse notified ER (emergency room ) nurse and the resident's husband. Ambulance here at 1:45AM and resident was transported per stretcher to ER. Review of the fall investigation revealed the intervention to the fall added by the fall committee/DON was for an auto nurse alarm. There was no documentation that the bed pad alarm sounded for the resident at the time of the fall and there was no documentation a floor mat was in place (as noted on the aide care plan that it was added 11/02/14 after resident returned with hip fracture from the hospital but it was not dated on the resident's careplan in record). Further review revealed Neuro checks were continued upon resident's return to facility around 7:45AM. There were no significant findings from the ER visit. 11/21/14 at 11:20PM in resident's room - nurse entered room and resident was noted to be sitting on the floor next to bed, and resident #2 stated, "I need someone to help me off the floor." No apparent injuries noted. Review of the investigation revealed it was unknown what the resident was trying to do. Bed was in low position and resident recently was started on Megace 40mg three times a day on 11/13/14. Review of the fall investigation revealed the immediate intervention after the fall was encouraged resident to call for assistance, CNA to sit by resident's door, bed in low position and call light in reach. Further review revealed the approach added by the fall committee/DON was that the auto nurse alarm had brought staff quickly and resident was found on mat. There was no documentation indicating the CNA sat by the resident's door for the remaining shift. Review of the staffing pattern revealed there were 6 CNA's working the night shift which is their normal staffing to cover the 6 sections. 11/22/14 at 4:45AM - resident's room - nurse was called to room per CNA, resident noted on floor, sitting facing the bathroom, states she needs help to get off the floor. Review of the investigation revealed resident was trying to go from the bed to the bathroom and was having frequent urination. The immediate intervention after the fall was encouraged resident to call for assistance, assisted resident to bathroom and then up in wheelchair with seatbelt on. The approach added by the fall committee/DON was scheduled toileting every 2 hours even at night. There was no documentation the auto nurse alarm sounded for the resident at the time of the fall and no documentation the mat was in place. (According to previous approach implemented immediately after previous fall that occurred 5 hours earlier revealed the CNA was to sit by resident's door). Review of the staffing pattern revealed on 11/22/14 there were only 5 CNAs working the night shift to cover the 6 sections of the facility. 11/22/14 at 3:25PM in resident's room - Resident sitting in recliner and slid out of it to the floor. Active range of motion to upper and lower extremities and no pain or discomfort noted. CNA's and nurse assisted resident up in wheelchair with seatbelt in place. Res up propelling in wheelchair with no signs of any acute distress. Review of the investigation revealed resident #2 was trying to ambulate without assistance from recliner because she needed to go to the bathroom. Immediate intervention after the fall was encouraged staff to get resident up at shift change for closer monitoring and toilet every hour. Intervention added by the fall committee/DON was for a pommel cushion in recliner. 11/24/14 at 2:50AM - around 2:45AM CNA was looking for resident, resident found lying outside on ground by unit front door lying on right side with wheelchair. Resident was awake and alert. Raised area noted to right temporal area, moderate amount of blood noted on ground. Ambulance called to transport resident to ER and they arrived around 3:00AM and at 3:10AM resident was transferred from the facility to the ER. Review of the fall investigation revealed it was unknown as to what the resident was doing and it was noted the resident was last seen at 2:30AM in the hallway. Head injury was noted and resident was immediately sent to the emergency room . There was no documentation the resident ' s seat belt alarm was in place at the time of the fall and there was no documentation that the wander guard alarm sounded prior to resident #2 eloping from the facility. Review of the statement made by S4CNA revealed she was making rounds at 2:10AM and when she finished her rounds, she was called to assist another resident to the bathroom at 2:30AM. She further reported she last saw resident #2 before entering the other resident's room. Review of the hospital discharge summary revealed an admission date of [DATE] and discharge date of [DATE] with [DIAGNOSES REDACTED]. Further [DIAGNOSES REDACTED]. Review of the nurse notes dated 11/07/14 at 5:36PM revealed resident #2 returned back to the facility with orders for PT/OT evaluation and weight bearing as tolerated. Review of the facility's policy and procedure for falls revealed the facility should identify the cause of a fall within 24 hours including but not limited to time of day of the fall and whether there is a pattern of falls for this resident. The staff should continue to collect and evaluate information until they either identify the cause of falling or determine the cause can not be found. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequence of falling. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued relevance of current interventions. If falling recurs despite initial interventions, staff will implement additional or different interventions. The staff should monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. On 12/09/14 at 10:15AM interview with S6ADON revealed she wasn't aware of what each symbol meant that were on the resident's name plates. She reported to the surveyor she knew the dolphin meant dehydration but she had to go and check to see what the other symbols meant. She returned after about 5 minutes and informed surveyor what each symbol meant. On 12/09/14 at 1:00PM interview with S8CNA Supervisor revealed resident #2 does have a wander guard in place because she will go to the doors. As far as she knows, she can't open the doors herself. The alarm will sound if she gets too close to the door. Observation revealed she was cleaning underneath resident #2's nails and at that time, resident reported to surveyor that she wanted to go home. Also at this time, it was observed that resident could unfasten her self- releasing seatbelt alarm. S8CNA Supervisor further reported that resident could take a few steps but she had an unsteady gait and balance. On 12/10/14 at 9:30AM interview with S9CNA reported resident #2 tries to go out of the doors and she can get out. On 12/10/14 at 10:45AM interview with S10CNA reported she worked the day shift and when she gets to work resident #2 usually already up. She further reported resident can undo her self-releasing seatbelt. Reported resident wanders around the nursing home in her wheelchair. S10CNA reported she has never seen her go out the doors. Reported it is hard to keep her engaged because her attention span was very short. S10CNA further reported resident #2 could transfer herself but not safely. On 12/10/14 at 11:00AM interview with S7AD reported resident #2 has a very short attention span and does not participate in activities very well. She reported she is extremely busy and wanders aimlessly in her wheelchair all throughout the facility. Reported resident #2 will attempt to go outside and can get outside by herself. On 12/10/14 at 11:30AM interview with S3DON reported the facility is divided into 6 sections at night and they staff with 6 CNAs . Review of the nurse staffing pattern revealed on 11/02/14, which was one of the nights resident #2 was found lying on the floor beside her bed, there were only 5 CNAs working the night shift from 10PM-6AM. On 12/10/14 at 11:40AM interview with S5LPN via telephone interview reported she worked the night of 11/02/14 when resident #2 fell which was the fall that occurred prior to resident being diagnosed with [REDACTED]. S5LPN reported the bed was in the low position when the resident fell but she went ahead and reinforced to the CNAs that night to always make sure it is in the low position. Reported resident #2 gets up through the night and she was always confused. She further reported resident #2 was usually restless through the night and she never remembered to use the call bell to ask for assistance and would attempt to transfer herself. S5LPN reported resident #2 had upper and lower extremity range of motion after the fall and didn't exhibit signs of pain or injury on her shift. On 12/10/14 at 11:53AM interview with S3DON reported the auto nurse alarm had a dual plug in which one plug was hooked to the bed pad alarm and the other plug hooked into the call light system. She further reported when the alarm goes off it sounds at the nurse station and it will not go off until a staff member goes into the resident's room to reset the call light box. She further confirmed the night of 11/14/14 there were only 5 CNAs working when they usually staff with at least 6 CNAs. On 12/10/14 at 5:30PM interview with S1ADM, S2Corporate Administrator and S3DON confirmed the fall Incident and Accident reports for resident #2 were not thoroughly investigated, staff failed to document what if any interventions were in place at time of each fall and there were no new approaches implemented after each fall. S2Corporate Administrator further reported when it was noted that nursing aide staff were instructed to sit outside resident #2's doors it did not mean continuously. He further reported the CNAs had to continue to make their rounds and respond to any other call lights that went off in their section; therefore they were not there at all times. He further reported the facility does not have the doors that lock for the wander guard system. They only lock from the outside at night. The MDS dated [DATE] revealed sampled resident #2 to be severely cognitively impaired. Documentation in the facility's nurses notes revealed the resident continued to get out of bed and her chair after being asked to call for assistance. Resident #2 had 9 falls between 10/17/14 - 11/24/14 with 7 falls occurring on the night shift from 10PM-6AM . The facility had not tracked and trended the falls to identify that 5 of the falls occurred on the night shift on a Friday, Saturday or Sunday, two of the falls occurred on a Saturday day and the other 2 falls occurred on a Monday night. Their normal staffing pattern was 6 CNAs on the night shift from 10PM-6AM; however there was no evidence that staffing had been increased when they said that staff would be seated at the door outside resident #2's door. Interview with S2Corporate Administrator reported the CNAs did not continuously sit outside the door because they still had to continue to make their rounds and respond to any other call lights that went off in their section. Review of the nurse notes from 11/22/14 revealed resident #2 was having increased urination and would void about 15mls. On 11/24/14 at 2:50AM resident #2 was found lying outside on the ground by the unit front door on the right side of her wheelchair. There was no evidence provided by the facility that supervision had been increased or that efforts were made to identify why the resident continued to get out of the bed or her chair frequently. The facility did not follow its own Policy and Procedure for falls.

Based on record review and interview the facility failed to conduct a comprehensive and accurate assessment of each resident's needs. The facility failed to: 1) assess a cognitively impaired resident after each fall for any patterns that could identify the cause of her falls for 1 (#2) of 5 (#1, #2, #3, #4 and #5) sampled residents reviewed. 2) ensure risk assessments were updated and current for 3 (#2, #4 and #5) of 5 (#1, #2, #3, #4 and #5) sampled residents reviewed who had a history of [REDACTED]. This failure placed resident #2 in an Immediate Jeopardy situation which began on 11/07/14 at 5:36PM after the resident returned back to the facility from the hospital with a [DIAGNOSES REDACTED]. S1 Administrator, S2 Corporate Administrator were notified of the Immediate Jeopardy on 12/11/14 at 3:11PM. The facility submitted a plan of removal which included: 1) Resident #2 will be provided one on one supervision until transferred to a safer environment. Will work with MD and family to arrange safe location. 2) All residents have the potential to be affected by the deficient practice. 3) Will in-service staff on fall prevention, fall investigation, filling out I&A properly to assess if current interventions were in place and that a new appropriate intervention was put in place. DON and ADON will track and trend all I&A's and change fall prevention needs as needed. DON/ADON/Administrator/Designee will physically monitor staff supervision on night shift 3 times per week for 4 weeks including weekends, then randomly thereafter to ensure safety is maintained. 4) If any problems are found they will be addressed at that time. The Immediate Jeopardy situation was removed on 12/12/14 at 9:47AM when the above plan of removal was accepted. The deficient practice remains at level of actual harm. Resident #2 Review of the medical record revealed resident #2 was a [AGE] year old female that was admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. Review of the Fall Risk Assessment updated 08/05/14 revealed a score of 13 which indicated resident #2 was at high risk for falls. (Fall Risk Assessment had not been updated in past 90 days). Review of the December 2014 physician orders [REDACTED]. Review of the 09/22/14 quarterly MDS, documented a reentry date of 08/05/14 from psychiatric hospital. Review of the MDS revealed resident was severely cognitively impaired, required supervision/set up help with bed mobility, transfer, walk in room/ corridor, and locomotion on and off unit. Further review revealed resident #2's balance was not steady with walking, was occasionally incontinent of bladder and always continent of bowel. On 12/9/14 at 10:30AM observation revealed resident #2 was self propelling herself in a wheelchair down the hall. Resident able to voice her name to surveyor but was confused. A bruise was noted to the right side of her face in the cheek area and a large knot noted at right temporal area. The surveyor questioned resident #2 about what happened and she stated she didn't know. On 12/11/14 at 11:10AM observation revealed resident #2 wandering around the facility in her wheelchair. Resident was observed to go up to med cart and start taking med cups off of the cart. Review of the Incident and Accident Log for resident #2 revealed a total of 9 falls from October - December 2014. Falls listed on the log were as follows: 10/17/14 at 2:21AM - resident found sitting on buttock in front of her wheelchair in the hallway. Resident reported she was trying to sit down in her wheelchair and fell on to the floor. Wheelchair wheels were not locked. 10/27/14 at 10:40PM - in resident's room. Nurse called to resident #2's room by the CNA. Resident noted on floor beside bed in seated position. Resident stated she did not remember why she got out of bed. 11/01/14 at 6:18AM - resident's room. Resident found on floor on side of bed sitting on buttocks. Resident had bowel movement on her body. Resident reported that she "fell going to the bathroom". Review of the fall investigation revealed resident was going from bed to the bathroom with complaints of diarrhea. 11/2/14 at 1:30AM - nurse was summoned to resident's room by the CNA. When she arrived, the resident was lying on the floor beside her bed. Resident stated, "I fell out of the bed." Review of the nurse notes dated 11/03/14 at 10:20PM revealed resident #2 complained of upper leg pain upon movement. No redness or swelling noted and there was adequate range of motion. MD notified by fax. There was no documentation an assessment was made of resident #2's pain during the night shift. Review of nurse notes dated 11/04/14 at 10:57AM revealed the nurse went down to room to assist CNA with dressing resident #2. When trying to get her pants up, resident yelled out in pain when her leg was picked up. Resident sent to hospital for evaluation. At 2:15PM the facility was advised resident #2's hip was broken. At 2:59PM, nurse spoke with hospital and was informed resident went straight from the emergency room to surgery. Review of the hospital discharge summary revealed an admission date of [DATE] and discharge date of [DATE] with [DIAGNOSES REDACTED]. 11/14/14 at 1:15AM in resident's room. This nurse was summoned to resident #2's room by the CNA, resident was found lying on floor on her back. She had removed her brief and verbalized that she had tried to go to bathroom and I think I hit my head. 11/21/14 at 11:20PM in resident's room - nurse entered room and resident was noted to be sitting on the floor next to bed, and resident #2 stated, "I need someone to help me off the floor." No apparent injuries noted. Review of the investigation revealed it was unknown what the resident was trying to do. 11/22/14 at 4:45AM - in resident's room - nurse was called to room per CNA, resident noted on floor, sitting facing the bathroom, states she needs help to get off the floor. Review of the investigation revealed resident was trying to go from the bed to the bathroom and was having frequent urination. 11/22/14 at 3:25PM in resident's room - Resident sitting in recliner and slid out of it to the floor. 11/24/14 at 2:50AM - around 2:45AM CNA was looking for resident, resident found lying outside on ground by unit front door lying on right side with wheelchair. Resident was awake and alert. Raised area noted to right temporal area, moderate amount of blood noted on ground. Ambulance called to transport resident to ER and they arrived around 3:00AM and at 3:10AM resident was transferred from the facility to the ER. Review of the fall investigation revealed it was unknown as to what the resident was doing and it was noted the resident was last seen at 2:30AM in the hallway. Head injury was noted and resident was immediately sent to the emergency room . Review of the facility's policy and procedure for falls revealed the facility should identify the cause of a fall within 24 hours including but not limited to time of day of the fall and whether there is a pattern of falls for this resident. The staff should continue to collect and evaluate information until they either identify the cause of falling or determine the cause can not be found. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequence of falling. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling and will re-evaluate the continued relevance of current interventions. If falling recurs despite initial interventions, staff will implement additional or different interventions. The staff should monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. A review of the fall history as listed on the Incident/Accident logs revealed the following patterns: 7 of the 9 falls occurred on the night shift from 10PM-6AM; 6 of the 9 falls occurred on a weekend (Friday, Saturday or Sunday); 2 of the falls occurred on a Monday night and 3 of the falls indicated that the resident was trying to go to the bathroom. The facility did not identify these patterns of falls for resident #2 On 12/10/14 at 5:30PM interview with S1ADM, S2Corporate Administrator and S3DON confirmed the fall Incident and Accident reports for resident #2 were not thoroughly investigated. Resident #4 Review of the medical record for the resident #4 revealed [DIAGNOSES REDACTED]. Review of the fall risk assessment dated [DATE] revealed resident #4 was at high risk for falls with a score of 14. Review of the wandering/elopement risk assessment dated [DATE] revealed the resident was cognitively impaired and was demented. It did not indicate if the resident was at risk for wandering. Review of the nurses notes dated 12/07/14 at 1:00PM revealed resident #4 was noted ambulating outside of facility, staff obtained resident from outside and questioned him about being outside, he states I was going home. MD notified and an order was obtained for a wanderguard to be placed on resident #4. Resident #5 Review of the medical record revealed resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Fall Risk Evaluation for Resident #5 revealed that the last evaluation was dated 06/23/14. The total score was 20 and placed the resident at high risk for falls. Review of the record for resident #5 dated 11/13/14 revealed that Resident #4 was found sitting on the floor beside her bed. According to documentation, the resident had kicked both bolsters off the bed and one of the bolsters unplugged the bed alarm. On 12/11/14 at 8:00AM interview with S6ADON reported to the surveyor the MDS coordinator who was responsible for updating the above assessments has been out on leave from the facility. S3DON was notified of the assessments that had not been updated for residents #2, #4 and #5.